18 November 2009

The Texas Medical Board ruled on Oct. 20 that physicians certified by the American Board of Physician Specialties (ABPS) could advertise themselves as board certified to the public.

The ABPS is the certifying body of the American Association of Physician Specialties (AAPS). The ABPS sponsors 17 boards of certification, including the Board of Certification in Emergency Medicine (BCEM).

For a number of years, ABPS, in conjunction with AAPS, has been seeking recognition from various state medical boards, requesting that they allow physicians certified through an ABPS board to advertise themselves as board certified. The organizations were successful in Florida in 2002 but were recently rebuffed by the State of New York due to the lack of residency training as a qualification for ABPS board certification.

ACEP does not recognize BCEM as a certifying body in emergency medicine.

This is bad. I've mostly stayed out of the internecine squabbles in the house of medicine, for a variety of reasons. Mostly because 99% of the issues are incredibly petty and provincial; for that reason I have a hard time getting/staying interested in these issues. This is a little different.

For background, the certifying body for Emergency Physicians for the last 30 years has been the American Board of Emergency Medicine (ABEM), which itself is under the umbrella of the American Board of Medical Specialties (ABMS), which has been the standard board certification organization of all allopathic physicians for the last 75 years. There is a companion organization for osteopathic physicians. The ABPS is relatively new in the last three years, though it is an offshoot of an organization which has been around for about 25 years, and it also purports to provide Board Certification in various specialties.

As it relates to Emergency Medicine, the ABPS is problematic. Specifically, it allows physicians to seek certification in Emergency Medicine without completing a training program in Emergency Medicine. It accepts training in a Primary Care specialty or, oddly, Anesthesiology, as equivalent to an Emergency Medicine residency. As best as I can tell, Emergency Medicine is the only such specialty certification for which the ABPS does not require completion of an ACGME-certified specialty training program. Residency training is required for ABPS certification in Radiology, Ophthalmology, Family Practice, Anesthesiology, and Orthopedic Surgery, at least. Why is Emergency Medicine held to a different, lower, standard under ABPS?

Unlike the other specialties, there are thousands of doctors practicing Emergency Medicine who are not residency-trained. This is in part an anachronism due to the relative youth of Emergency Medicine as a specialty; there are many ER docs who have been working in the ER since well before the ABMS recognized Emergency Medicine as a distinct specialty. It is also true that there are more ER positions than there are residency-trained graduates of EM residencies, and this is likely to remain the case for the foreseeable future. Even as new training programs open, the rate of graduation of new residents barely makes up for the retirement of practicing ER docs, let alone makes up the gap in the number of untrained ER docs.

Even today, many young primary care docs tire of the drudgery of office practice and give it up for the easier lifestyle and higher compensation of the local Emergency Department. Many small ERs, especially those in rural areas, have trouble attracting good physicians and as a result are willing to credential almost any physician willing to staff their department. This is not an ideal circumstance, of course, but when your ED cannot find doctors any other way, it does become something of a buyer's market.

So it is necessary to recognize the existence of the thousands of moonlighters and other variously-competent doctors working in the nation's ERs; it's a reality that is not going to go away any time soon. It's actually a good thing that there is a certifying body that can guarantee some minimum level of competency for these practicing physicians. As long as we have the necessary but undesirable situation of untrained physicians working in the ED, I am not opposed to the existence of the AAPS program.

What I am opposed to is the dishonesty of these physicians and their organizations in presenting themselves to the public as "Board Certified." This is misleading in the extreme. Board Certification has always been held to mean a high standard of training and accomplishment. It is a standard across 24 specialties. For an alternate organization to set itself up and promote a lower standard is disturbing. More disturbing is the manner in which the ABPS/AAPS slipped this in through the Texas Medical Board apparently in the dead of night with no public discussion. If there is to be equivalency between ABPS/AAPS and the ABEM, it should be agreed upon after a full and open debate. For myself, I do not think that this equivalency is merited. The ABPS is like ACLS and ATLS -- a nice merit badge to show that you're not likely to hurt anybody while working in the ER, but not the same as a specialty training certificate. But if Texas (or any other state) medical board decides otherwise, then that decision should be the product of a public debate and consensus among the physician leaders in that state.

If the implication of the linked article is accurate, this decision was the result of a shameful bit of political sleight of hand. I hope that ACEP is successful in reversing this ruling.

Ultimately, this is a manpower situation that Emergency Medicine needs to come to grips with. While new residencies continue to open in drips and drabs, and existing residency programs expand a bit, the rate of increase is far too slow. Unfortunately, the funding from Medicare which underwrites the cost of graduate medical education is very hard to come by in this difficult budgetary environment. In an ideal world, the residencies would grow to the point that all Emergency Physician positions would be filled by, you know, trained Emergency Physicians. I don't know whether that will happen in my professional lifetime. The consequence is that many of the nation's Emergency Departments will continue to be staffed by untrained doctors of uncertain quality. That is a pity for the patients who come through the doors, who are after all a captive audience, unable to make a choice of their treating provider. They deserve better.

31 comments:

As a brand-new ER guy who just finished a grueling EM residency and is seeking ABEM certification, I'm mildly interested in this little controversy.

I agree with you -- the words "board certified" are generally understood to mean "residency trained", so this decision by the Texas board could lead to some misunderstandings.

The question is, who will misunderstand? And does it really matter?

The public will probably be confused, but how significant is that? Members of the public don't choose their emergency physicians the way they do their Botox providers. They go to the nearest hospital, and they trust that the hospital will arrange for a competent ER doc to take care of them.

Hospitals -- I hope -- recognize that ABEM is the usual "board" that does the certifying of emergency physicians. When a doc claims that he's board certified by the BCEM, I don't think it's likely that the hospitals will confuse this with ABEM certification.

Of course, if I'm right, then how come the ABPS diplomates want so badly to call themselves "board certified"? Are they simply seeking recognition of their experience working in ERs? If so, I'd like for them to have it -- so long as they don't hold themselves out to be residency-trained.

If you want to know whether a new doc has the skills to work in an ED, maybe board certification is a quick way of verifying that the doc has had the training and has the basal level of knowledge. Instead of residency training, ABPS takes into account one's "real world" experience working in the ED. Why is this a "lower standard"?

The further you get from residency, the less of a difference there is in skill sets.I've seen non-residency trained docs that run a room better than residency trained ones and I've seen residency trained docs that can't intubate and have no idea how to use a slit lamp.

Board certification essentially means that you're smart enough to pass a test (and that you've paid the rather large testing fees). If you're not even allowed to take the test to show how smart you are, how does that make you any less competent than someone who got the minimum passing grade?

If you're worried about the care that patients get, do you really think someone with an MI checks the credentials of the doc working in the ED before getting treated?

Unless the ABPS exam is a farce, I think it is unfair to accept one physician's competence and/or skill set because they passed one test while assuming the opposite if they passed a separate test.It all comes down to competency, and I'm not convinced that one type of "board certification" is any better than another as a way to measure a physician's skills.

Kind of like trying to judge physicians based on patient satisfaction scores ...

WhiteCoat -- It ain't the test, it's the training. If the ABPS board certification required an EM residency, as it does for every other specialty, I would probably not have much of an opinion as to which board certification was preferable.

And I'm not sure it's true that "the further you get from residency the less different in skill sets." It depends on what your experience has been. If you're working in a busy Level 1 trauma center, then it's true that a BCEM guy probably does have all the requisite skills after ten years. In my limited experience, not working in Texas, the BCEM guys I have met, and those whose CVs I have reviewed, more typically are working in less-desirable positions in Level 4 centers with annual volumes of 12,000. Whether they have had the exposure to acquire the essential skills of EM in that sort of environment is an open question in my mind. (It's also fair to say that a residency graduate who works exclusively in Podunkville may have some of their skills atrophy through disuse!)

And on a purely philosophic level, I'm disturbed about the acquisition of those "real world" experiences by untrained and unsupervised docs. Ideally, when you are dealing with your first (fill in the blank) critical case, you've got an attending over your shoulder helping you out. Trial and error is a fine way to learn but a crummy way to provide care.

"Real world" experience in my ER includes administrators not caring if a doctor tubes his own patient (call anesthesia!! for every patient), sending the patient to the ICU to get a central line put in by the intensivist, doing big work-ups on everyone because they really never learned how to rule out/in the bad stuff and either d/c or admit, and having ortho come down and reduce all dislocated shoulders.

Tell me again why "real world experience" = "residency". What would happen if these doods used to my multi-specialty hospital where everything can be delegated were suddenly were put in a rural ER with no other docs in the house? They'd kill someone and/or have to call 9-1-1 to have their patients tubed or whatever. You'd think that a board-certified doctor should be able to do a certain set of basic skills everywhere under any circumstance.

I, for one, see a ginormous difference. I'll bet that all the doctors could pass the same written test, but some doctors were meant to do ER (personality, like fast-paced work, not fearful of making decisions based on limited info) and some failed out of a surgery residency and do ER because that was the only place that would hire them in 1983.

I agree with you and K on this one. I can't just start my own board certification process for general surgery and call it "BOB's Surgical Certification" and administer an exam and board people. Of course WC, there are some individuals who are great who are not boarded or residency trained but in general, there is much less disparity once you have done a residency. Also, we are talking about the future of EM. The future should have all ER docs EM boarded, not "Bob's who-knows, half-assed board of physician specialties" trained.

what about those board certifications which expire? are you less of a practitioner if you don't keep paying exorbitant fees and taking tests, as long as you have gone through residency and passed the test once?why should older practioners get to be permanently (board) certified and not younger ones too?

If ACEP was really concerned about patient care they would devise an additional training track for non EM residency trained physicians to gain additional training in EM. It is well documented that there are not enough EM residency physicians to fill all the ED jobs in the country. This clearly shows that this is a turf control and money issue for ACEP and not a patient care issue. ACEP continues to try to block ABPS from trying to provide certification for qualified ED physicians.

Mark Luce MDWe live in trying and dificult times. Greed and hipocricy got us here. True concern for others and teamwork will be needed to get us out. Working to adress the needs of patients and communities and physicians and health care systems is supposedly occurring on all levels as we speak. The findings of the State Board of Texas (venerable home of many, including such level headed and pragmatic minds as Ron Paul) should be welcome news to those who value the principles that made our country great.Competition is know to many as a good thing for the end product delivered. I have served as director of EM in multi-provider facilities, and all of us with depth of experience must acknowledge that training and experience are both needed to obtain the best physician. For the situation we are in, it is well to do our evaluation on the end product. I believe the Texas board did a thorough and compitent job.

Way to go, Texas. The patients win in the obviously financially motivated exchange. I agree with Nurse K, that if you put most "residency trained" docs in a high trauma rural situation, they would fold. I have done both and rural definitely requires more confidence and skills. When I worked high level trauma center, everyone else did my work (residents, anesthesia, etc) and skills rusted. This is stupid, money driven argument and yay for Texas and yay for patients.

This is a very sore topic in most places. Our ER is covered with Board Certified EM docs and some old timers who have Board Certification in IM or FM and I find that they all are as good as others. They all intubate the patients that need intubation, they all reduce the shoulders, and they are all good docs. I think that ACEP is trying to close the door on the many physicians who could have easily grandfathered in the specialty but would not allow them to do so.

There is so much posturing and anecdotal facts being passed along as gospel truth. I am one of those BCEM boarded ER docs that just missed grandfathering by 1 year. I work in a small town but busy ER where very few are ACEP "grandfathered" boarded. We have had many RT docs join us throughout the years but none stayed. Some were fired for plain incompetence.(Interestingly all the fired docs were RT trained!) The area is poor and semi remote and the work is very rigorous with practically no support services. We do all our own intubations, chest tubes, central lines, orthopedic reductions as well as all the critical care emergencies in the entire hospital.This ER is not for the freshly minted ED grads!So please quit spreading the fallacy that only RT ER docs can do a superb job in the ER. In the last 17 years working in this ER I have come across RT docs who should not be working in any ER let alone touch a patient.The future trend is for only RT trained docs to work in the ER. Yes, that is a good thing. The present reality is that there are not enough RT trained docs to staff all the needed positions. My training background was one year internship in medicine and three years in general surgery. This training included running the OB/Gyn, Orthopedic/Burn clinics and the Surgical Critical care Unit. Oh, by the way, I was also a 2 year Surgical Nutrition Fellow at Johns Hopkins University Hospital where part of my job description was to put in central lines for TPN (over 2000--yes that is thousand and not a typo, with one small PTX). I ended up in the ER because of personal circumstances. I challenge anyone to show me any ER residency training program that can match my background training. I also challenge any of you trash talking ABPS and BCEM to take their exam. Get off from your high horses and let us all work together and support one another as ER docs in improving access and care to all ED's across the nation. We must also remember that continuing education is much more important than the knowledge garnered at some training program eons ago.

So guys, If you want to find a good mechanic, you ask your friend at the car dealership or some such person. If you want to know about ER docs, you ask another physician who deals with the ER docs. I was a hospitalist for many years and now an interventional Cardiologist. So my sense is that what residency teaches these new grads is how not to let anyone go home from the ER. Patient walks in and they have to decide go home or come in. Where is the medicine in that? Sure there are occasions when intubation/chest tube is needed but even the EMTs can do that stuff. You make doctors not to do ACLS procedures but to execute critical diagnostic thinking which is so missing from ER residency trained docs. Besides when I used to go to the community hospital I always found older docs who I assume were not residency trained and they did a lot more for their patients then you see ER docs do in trauma centers. I think they should do away with ER residency and create a fellowship after either IM or FP residency or both. That is just my two cents.

I have seen some great non EM RT docs, but unfortunately have also seen some pretty bad ones. The same can be said for EM RT docs. It all depends on experience and how much self education one has committed to. Wouldn't it be nice if the ABEM would again allow these docs to certify, like they did in the past? They could even call it a 'class B' certification or some other name to distinguish it from the EM residency trained docs. We need these docs (the good ones) to fill the demand of EM, why not allow them to certify and prove they are capable.

The fact of the matter is that many older physicians who were practicing before any residency existed are now BCEM board certified. The notion that a young doctor just graduating from residency is more qualified than a doctor who has practiced sometimes decades, is laughable and just won't sell anymore. The reason they didn't do a residency is that they were too busy inventing it!

semi accidental shorin ryu practitioner, you ought to know better than to write this diatribe. Your understanding of the issue(s)is infantile. Allow me to use an example that I hope will make you pause and re-think.

In the martial arts, an organization creates a certification of let's say, martial artists. shorin ryu practitioners join and other martial artists join. eventually, the members of that group decide to close the path to certification.

They then close the track that would allow other martial artists to enter. Those martial artists continue to teach, in some places they even teach the members of the organization. They also continue to practice.

Eventually the certified group lobbies so that the non certified group find it harder and harder to find a place to practice. The certified group tell dojos that only they the certified ones, can teach/practice martial arts well. The others are substandard.

The certified group eventually graduates students, those students preach that only with their training can one practice skilled martial arts.

You mentioned ACEP. This is very interesting.I am a Canadian ERCphysician.I am not Residency trained .Neither are 80 percent of Candian ER physicians.Most of us come from Family Practice programs with an extra year spent in ER. Yet most of my colleagues proudly display th ACEP designation they were granted prior to 2002.In fact ACEP granted their logo to non ER physicians.Some of those are International Grads.I was astounded to find they are ACEP members.Ihappen to know many of them are not Residency trained.I was further inspired by your article, and looked up ABPS website .Imagine my disappointment when I found out that I am one of the 80 percent of Canadian ER docs who are NOT eligible to apply to the ABPS (unless we were all trained in Tennessee, this was an exception), or if I was an anaesthesiologist!!!It is all there in their website,under Elgibility requirements,itemS 7& 8.No Sir,with all due respect ,Regardless of the time of day the Texas Medical Board recognized the ABPS certification,it is obvious that ACEP did at one time loosely associate Residency training with ER.

The majority of ABEM physicians are NOT ER residency trained and have been allowed to grandfather into ABEM with the SAME OR VERY SIMILAR qualifications as the BCEM doctors. There seems to be quite a bit of hypocrisy in the ABEM group thinking that the non residency em ABEM members are any better or even have any different qualifications to do ER work than the BCEM physicians. Get off your high horse, and accept the fact that ABEM wants BCEM not to be recognized simply because of political and FINANCIAL motives!!! I've been doing full time ER work for 20 years, and I feel like I'm more qualified to handle some cases that even these brand new graduates (from an ER residency) are.

I'm a Internal medicine trained gut who has been doing fulltime er work for over 20 years now. Back when I first started, your success in the field was mainly dependent on the nursing staff i.e. if they didn't like you for some reason or they were scared to work with you then your career as an er doc was often measured in days or weeks instead of years. Thats probably the reason you just don't see a lot of bad BCEM doctors working in er's for 20 years.Residency trained guys are different. If you're bad eventually they'll get rid of you, but because you are ABEM, FACEP,FAEEM, etc. you will most certainly be hired somewhere else. I knew one doctor who was absolutely terrible and lasted only a few mos. That doctor went back and did an ER residency and resurfaced at another ER that I worked at parttime. Guess what, she was worse than before. But she'll always get better jobs that wouldn't give me the time of day because she's residency trained.

You should make sure that your facts are straight before stating your point. A brief history: Emergency medicine is a relatively young medical specialty with the first residency program established in 1971 and the first board certifying exam in 1979. The Cincinnati residency wasn't even called EM it was Ambulatory Care Medicine.Prior to residency programs, the emergency department coverage was staffed by physicians in other specialties including internal medicine, family practice and surgery. These physicians in other specialties were able to take the certificationexam given by ABEM until 1988. This arbitrary date didn’t address the continuing need for non-ABEM, non-emergency medicine residency trained physicians, particularly in rural areas, nordid it anticipate the huge physician shortage that we are facing presently. The Association of American Medical Colleges (AAMC) expects a needed physician increase across the board of nearly 40% and likely higher numbers in states likeFlorida and Texas. The AAMC has already called for a 30% increase in medical school enrollment and this has not happened.

AAPS was incorporated in 1952 and has offered certifying and re-certifying exams in various specialties since 1984 (25 years not 3 years as posted).

We all agree that we want to improve the quality of care. But when we get right down to it, any board certification is just another test. When 38-43% of ABEM certified physicians have not done a residency but are considered equal, this is hypocrisy at its best. If we are truly looking to improve quality of care for our patients, BCEM is another benchmark which has been shown to be valid and equivalent to ABEM through independent testing. This is one of the ways to raise the bar of practicing ER physicians who graduated too late for the arbitrary cutoff of the ABEM practice track.

I am the chairman of the Association of Emergency Physicians (www.AEP.org) and our organization's position is that we support all emergency physicians regardless of training or certification with our ultimate goal of improving the quality of of patient care. I have been practicing in emergency medicine for the last 16 years and a diplomate of BCEM since 1999. I am presently practicing in a 56,000 volume ER. I have no problem with stating that my certification was BCEM but I do feel that I should be able to advertise as a board certified physician since I have met the same standards as my "grandfathered" colleagues. My patients have never asked me about my credentials in all of my years of practicing. There are far more important issues regarding patient care in emergency medicine than whose board was taken.

Shadowfax, just allow me to point out what a hypocrite you are. ABEM in the 1990's was doing EXACTLY the same thing that BCEM is now doing, i.e. grandfathering primary care MDs into emergency medicine based on years of ED experience. Shall we revoke all the ABEM certifications of those docs? How many EM residencies to you think is equivalent to 20 years of real world ED experience? At least BCEM recognizes (as did ABEM at one time) that with a certain amount of experience, you can provide quality care in the ED. Until there are enough EM residency trained docs to staff all EDs everywhere, shouldn't someone be certifying the competence of those who are actually practicing emergency medicine in the trenches?

The new President of ACEP; Sandra Schneider is "Board Certified" but did her residency in Internal Medicine. Why can she say that she is Board Certified. Did anyone say anything about quality care? Many of the "residency trained" and "Board Certified" EM docs are not necessarily quality docs. Many of us have been practicing EM for MANY years and provide QUALITY care. We should be able to advertise as board certified, just as so many others like ACEPs new president who are NOT residency trained!

As an "Old Guy" in EM time has changed my perspectives. My training was one year of FP, then GMO in Indian Health 3 yrs., then General Surgery, ABEM Boards therein and 10 yrs of rural practice (Appalachia) during which I directed the ED and taught. Economic and personal changes moved me uptown where the need was not for General Surgery but for EM. I've practiced in my current ED now for 17 yrs. As Chief and Med Dir. for 14 yrs I've seen it add a level III trauma unit, go from 37K to 47K visits and become the go to department for all critical care procedures. In 2006, having decided for some reason that EM Boards might help I completed oral and written testing with BCEM and began declaring myself "EM Boarded". I also started working to replace myself in the ED. While working on a management degree at Tulane I took some of these skills and applied them to developing the ED. I agreed with prevailing wisdom to staff with emresidencytrainedboardcertified docs, grandfathering our best proven otheremdocs. As I moved into a new CMO position I left the ED in the hands of skilled ABEM EM doc. The best effects of this change have come from this doc having new connections with the EM residency in our nearby by Academic center. We are now fully staffed (not the case for 12 yrs)and with ABEM types in about 72% of those positions. Admin, Medical Staff, Patients, the University are all happy. I hope to be able to fashion several affiliated residencies in primary care specialites for the hospital, in part on the strength of our ED development. The community and patients and access to care are all improved as a result of this growth/development. ED quality of care? The quality of medical care, ED procedures, outcomes are all about the same (very good). Provider experience and skills, patient satisfaction, medical staff satisfaction all about the same too. There's less burn out and the dept. is more attractive to EM physician recruiting. We see more patients with better turn around times, less walkouts and I get less complaints from the ED docs and nurses. We do not have an ABEM requirement for practice. We will continue to do quality managment, OPPE and FPPE with our ED staff irrespective of their board source (our bylaws require that you seek board cert. as soon as qualified to do so). BCEM and ACEP are just terms in the individual physicians file. His/her ongoing quality of care remain our most useful guide for assesment. What has made the difference in this ED has not been the board affiliation but modern quality managment practices.

You neglected to mention ACEP's response to Texas' recognition of ABPS:(from original Central Line article) ACEP does not recognize BCEM as a certifying body in emergency medicine. The Texas Medical Board ruling came as a surprise to the emergency medicine community, said Dr. Angela Gardner, ACEP president"We are very concerned that this ruling was done without the input of any of the organizations representing emergency medicine,” said Dr. Gardner. “Neither ACEP, AAEM, the Texas chapter, nor to our knowledge, any other medical specialty organizations were asked to submit written comments or testify at public hearings.”After the ruling was announced, ACEP sent a letter to the Texas Medical Board asking for a clarification and requesting through the Texas Open Records Act, all documents, letters and communications relating to the ruling.

ACEP members who are not EM residency trained should ask themselves whether the ACEP leadership is protecting the interests of its EM residency trained members above their own, and if so, why are they contributing their hard-earned dues to an organization that publicly considers them as “second rate”?

This is not the first time that the ACEP leadership has campaigned against ABPS which allows non-EM residency trained physicians to take its EM certification exams. Florida ACEP chapter president Mylissa Graber wrote in an EM Pulse editorial:

“if a physician who is a family practice doctor chooses to work in these areas in the ED, that is fine, but s/he is still a family practice doctor,not an emergency physician and there is no shame in that.Just don’t misrepresent who you are.In the same way,when I do a pelvic exam, I do not tell the patient I am a gynecologist, and when I put in a chest tube, I do not say I am a cardiothoracic surgeon…This fight is not over and we will continue to pursue residency training in EM as the only appropriate pathway into emergency medicine today, but it is time for the emergency medicine residency-trained docs to stop sitting on the sidelines and join this fight. ”

The only reason that NY DOH does not recognize ABPS certification is because EM specialty organizations such as ACEP and AAEM actively campaign against it. (For history on the NY and Florida ABPS battles, go to:http://www.docwhisperer.wordpress.com)

The question begs to be asked, is ACEP only representing the EM residency trained/ ABEM certified docs? Seems like it, from Dr. Gardner’s comments. Her inclusion of AAEM (which rabidly campaigns against non-EM residency trained ER physicians) as an organization of authority that represents the specialty of EM is particularly troubling.

The problem lies in a difference of opinion regarding whether one should complete a residency to obtain board certification. ABEM currently requires it, and AAPS does not. AAPS physicians usually have board certification in another speciality, which is a requirement for BCEM certification, but ABEM states this is not the same as an ER residency. Nor is the 5 year practice requirement, although some would claim otherwise.

ABEM and ACEP refuse to accept the AAPS certification, because that would negate their position that a residency should be completed to obtain board certification.

A possible solution, would be a 1 year ER fellowship at the senior level. Entry would be contingent upon having obtained Board Certification in an approved primary care speciality, and 5 years of practice certification. Upon successful completion of this year at the senior level, and documentation of procedures done, the candidate should then be to sit for the appropriate exams for certification.

Currently, there are several paths to obtain board certification in Critical Care. One can complete a surgical residency, a pulmonary fellowship, or an anesthesia residency and complete a year of fellowship in Critical Care and be eligible to sit for Critical Care Boards.

Hence, there are several ways to become Board Certified in Critical Care, and all of these paths then lead to running an ICU, and there really isn’t controversy about who is better. Perhaps a similar route can be established for Emergency Medicine with AAPS taking the initiative in presenting this to ABEM, after establishing this as a requirement for their future candidates.

All of us would agree that family medicine residency is a good background for ER medicine, but is still not a substitute for ED residency. A family doc would have to brush up on reading x-rays, ct scans, and become skilled at intubation, chest tube placement, central line placement, trauma management. This could occur with supervision at the senior ED fellowship.

Working toward this would make more sense than filing lawsuits back and forth at the state level, with neither side really winning much of anything.

I am BCEM doc...just put bilateral chest tubes in an 8 month old - and intubated it, started fluids/antibiotics/pressors - the child lived. I was originally a dentist, went back to med school, did a transitional year, a radiology year, and an Internal med residency - have 15 years full-time ER experience. I don't know, you decide, can I do this job?

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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